Maternal and Child Healthcare.ppt

Dr. dr. SHIRLEY I. MONINGKEY MkesFamily and community departmentFoM Pelita Harapan University

>200 million women become pregnant each year585,000 women die each year20 million women develop chronic debilitating illnesses as a result of pregnancy-related complication75 million unwanted pregnancies50 million induced abortions20 million unsafe abortions (same as above)600,000 maternal deaths (1 per minute)1 maternal death = 30 maternal morbidities*

3 million neonatal deaths (first week of life)3 million stillbirths

*

Annually, 585,000 women die of pregnancy related complications 99% in developing world~ 1% in developed countries*

380 women become pregnant190 women face unplanned or unwanted pregnancy110 women experience a pregnancy related complication40 women have an unsafe abortion1 woman dies from a pregnancy-related complication*Every Minute...

50% (5.767) kematian ibu25% (2.884) kematian ibu25% (2.883) kematian ibuSumber: Laporan rutin KIA, 2010 & koreksi jumlah kematian ibu dg AKI menurut SDKI 2007

Chart1

837

668

627

250

208

168

156

152

150

130

121

120

120

116

113

105

97

94

83

78

77

77

73

71

60

56

55

53

50

42

40

39

32

2011

Sheet1

2011

JAWA BARAT837

JAWA TENGAH668

JAWA TIMUR627

BANTEN250259050.61

NUSA TENGGARA TIMUR208123324.09

SUMATERA UTARA168129525.30

ACEH1565118100.00

LAMPUNG152

RIAU150

NUSA TENGGARA BARAT130

SUMATERA SELATAN121

SUMATERA BARAT120

KALIMANTAN SELATAN120

SULAWESI SELATAN116

KALIMANTAN BARAT113

SULAWESI TENGAH105

SULAWESI TENGGARA97

KALIMANTAN TIMUR94

MALUKU83

DKI JAKARTA78

JAMBI77

MALUKU UTARA77

KALIMANTAN TENGAH73

SULAWESI UTARA71

KEPULAUAN RIAU60

D I YOGYAKARTA56

BALI55

PAPUA53

GORONTALO50

SULAWESI BARAT42

KEPULAUAN BANGKA BELITUNG40

BENGKULU39

PAPUA BARAT32

$5,118

JUMLAH KEMATIAN IBU DAN PENYEBABNYA2012 - NOVEMBER 2013Sumber Data : Data Rutin Kesehatan Ibu 2013Sumber : Data rutin direktorat Bina kesehatan Ibu

Chart1

781514

675419

582290

237142

178118

17288

170125

15873

15174

143107

14060

137195

10667

10360

10131

10079

10075

8686

8451

8139

7717

6931

6520

6326

5923

5623

5540

4950

4726

4627

4026

3838

3711

50% kematian (2.453 kasus 2012) (1.483 Kasus 2013)

25% kematian (1.280 kasus - 2012) ( 849 kasus 2013)


2012

2013

Sheet1

20122013

JAWA BARAT781514

JAWA TENGAH675419

JAWA TIMUR582290

BANTEN237142

LAMPUNG178118

NUSA TENGGARA TIMUR17288

ACEH170125

RIAU15873

KALIMANTAN BARAT15174

SUMATERA SELATAN143107

SULAWESI SELATAN14060

SUMATERA UTARA137195

KALIMANTAN TIMUR10667


DKI JAKARTA10131

SUMATERA BARAT10079


SULAWESI TENGAH8686

SULAWESI TENGGARA8451

MALUKU UTARA8139

JAMBI7717

MALUKU6931

PAPUA6520

BALI6326

SULAWESI BARAT5923

KEPULAUAN RIAU5623

KALIMANTAN TENGAH5540

SULAWESI UTARA4950

PAPUA BARAT4726

GORONTALO4627

D I YOGYAKARTA4026

BENGKULU3838


Sumber : Data rutin direktorat Bina kesehatan Ibu

KECENDERUNGAN ANGKA KEMATIAN BALITA, BAYI DAN NEONATAL, 1991 -201533%43%48%37%Proporsi kematian neonatal dibanding kematian balita meningkat

Chart1

326897

305781

264658

203546

193444

193240

2014242014

142332

Neonatal Mortality Rate

Infant Mortality Rate

Underfive Mortality Rate

Sheet1

Neonatal Mortality RateInfant Mortality RateUnderfive Mortality Rate

1991326897

1995305781

1999264658

2003203546

2007193444

2012193240

201424

2015142332

2020

2025

2035

Sheet2

50% kematian (86.111)25% kematian (42.845)25% kematian (41.313)

Sources; Basic Health Survey 2007Pneumonia, 12.7 %Diarrhea 15 %NeonatalProblems 46,2 %Meningtis, 4.5 %Kongenital Anomaliies 5.7 %Unknown 3.7 % Tetanus, 1.7 %NeonatalProblems 36 %Diarrhea 17.2 %Pneumonia, 13.2 %Kongenital Anomalies4.9 %Unknown 5.5 % Meningtis, 5.1 %Tetanus, 1.5 %

JUMLAH KEMATIAN IBU DAN PENYEBABNYA2012 - NOVEMBER 2013Sumber Data : Data Rutin Kesehatan Ibu 2013Sumber : Data rutin direktorat Bina kesehatan Ibu

Chart1

781514

675419

582290

237142

178118

17288

170125

15873

15174

143107

14060

137195

10667

10360

10131

10079

10075

8686

8451

8139

7717

6931

6520

6326

5923

5623

5540

4950

4726

4627

4026

3838

3711

50% kematian (2.453 kasus 2012) (1.483 Kasus 2013)



2012

2013

Sheet1

20122013

JAWA BARAT781514

JAWA TENGAH675419

JAWA TIMUR582290

BANTEN237142

LAMPUNG178118

NUSA TENGGARA TIMUR17288

ACEH170125

RIAU15873

KALIMANTAN BARAT15174

SUMATERA SELATAN143107

SULAWESI SELATAN14060

SUMATERA UTARA137195

KALIMANTAN TIMUR10667


DKI JAKARTA10131

SUMATERA BARAT10079


SULAWESI TENGAH8686

SULAWESI TENGGARA8451

MALUKU UTARA8139

JAMBI7717

MALUKU6931

PAPUA6520

BALI6326

SULAWESI BARAT5923

KEPULAUAN RIAU5623

KALIMANTAN TENGAH5540

SULAWESI UTARA4950

PAPUA BARAT4726

GORONTALO4627

D I YOGYAKARTA4026

BENGKULU3838


Sumber : Data rutin direktorat Bina kesehatan Ibu

KECENDERUNGAN ANGKA KEMATIAN BALITA, BAYI DAN NEONATAL, 1991 -201533%43%48%37%Proporsi kematian neonatal dibanding kematian balita meningkat

Chart1

326897

305781

264658

203546

193444

193240

2014242014

142332

Neonatal Mortality Rate

Infant Mortality Rate

Underfive Mortality Rate

Sheet1

Neonatal Mortality RateInfant Mortality RateUnderfive Mortality Rate

1991326897

1995305781

1999264658

2003203546

2007193444

2012193240

201424

2015142332

2020

2025

2035

Sheet2

*Current Approach to Reduction of Maternal Mortality

Delay in decision to seek careLack of understanding of complicationsAcceptance of maternal deathLow status of womenSocio-cultural barriers to seeking careDelay in reaching careMountains, islands, rivers poor organizationDelay in receiving careSupplies, personnelPoorly trained personnel with punitive attitudeFinances *Three Delays Model

Good quality maternal health services are not universally available and accessible> 35% receive no antenatal care ~ 50% of deliveries unattended by skilled provider ~ 70% receive no postpartum care during 1st 6 weeks following delivery*

Historical ReviewTraditional birth attendantsAntenatal care Risk screening Current ApproachSkilled attendant at delivery*

The flawed assumption: Most life-threatening obstetric complications can be predicted or prevented*

AdvantagesCommunity-basedSought out by womenLow techTeaches clean deliveryDisadvantagesTechnical skills limitedMay keep women away from life-saving interventions due to false reassuranceCurrent Approach to Reduction of Maternal Mortality*

Current Approach to Reduction of Maternal Mortality

Health system improvements:Introduction of system of health facilitiesExpansion of midwifery skillsDecreased use of home delivery and delivery by untrained birth attendantsSpread of family planningCurrent Approach to Reduction of Maternal Mortality*


*Current Approach to Reduction of Maternal Mortality85% births attended by trained personnel

Conclusion: TBAs are useful in the maternal health network, but there will not be a substantial reduction in maternal mortality by TBAs delivering clinical services aloneCurrent Approach to Reduction of Maternal Mortality*


Antenatal care clinics started in US, Australia, Scotland between 19101915New concept - screening healthy women for signs of diseaseBy 1930s large number (1200) ANC clinics opened in UKNo reduction in maternal mortalityHowever, widely used as a maternal mortality reduction strategy in 1980s and early 1990s

Is ANC important? YES!!Early detection of problems and birth preparation*

*Improvements in nutrition, sanitationAntibiotics, banked blood, surgical improvementsAntenatal careMaine 1999.

Proper training, range of skillsAssess risk factorsRecognize onset of complicationsObserve woman, monitor fetus/infantPerform essential basic interventionsRefer mother/baby to higher level of care if complications arise requiring interventions outside realm of competenceHave patience and empathy*WHO 1999.

DisadvantagesVery-poorly predictiveCostly: Removes woman to maternity waiting homesIf risk-negative, gives false security

Conclusion: Cannot identify those at risk of maternal mortality every pregnancy is at risk*

KELEMAHANPrediksi sangat burukMahal memberikan keamanan palsuSEBAGIAN BESAR WANITA YG DIMASUKKAN KELOMPOK RISIKO TINGGI TIDAK PERNAH MENGALAMI KOMPLIKASI

Pregnancy is a period of riskAny pregnant woman can have complication and dieAccurately predicting which woman will develop complication is not possibleEarly detection and management of complications is vital

Proven effectiveMalaysia: basic maternity services 320 157 Cuba: national priority 118 31China: facility based childbirth 1500 50Malaysia vs. Indonesia:Trained community midwives (2 year) vs. untrained midwives (4 years)*

komplikasiPengaruh pada ibuPengaruh pada bayiInfeksi saat hamil, STDPremature onset of labour, Kehamilan ektopik, PID, infertilitasPrematur, infeksi mata, kebutaan, pneumonia, stillbirth, sifilis congenitalhepatitisHPP, gagal liverHepatitisMalariaAnemia berat, trombosis serebralPrematur, IUGRUnwanted pregnacy,Unsafe abortion, PID, perdarahan,infertilityPeningkatan risiko mrbidits dan mortlitas, child abuse,neglectPersalinan tidak bersihInfeksi, tetanus Neonatal tetanus, sepsis

KomplikiasiPengaruh pada ibuPengaruh pada bayiAnemia beratCardiac failure B BLR, asfiksia, stillbirthPerdarahanShock, c.failure, infeksiAsfiksia, stillbirthHipertensiEklampsia, CVABBLR. Asfiksi, stillbirth Sepsis puerpuralisSeptikemia, shockSepsis pada neonatusPartus lamaFistula, ruptura uterin,prolaps, amnionitis, sepsis Stillbirth, asfiksia, sepsis, trauma lahir, cacat

Causes of maternal deathsProven interventionPostpartum HaemorrhageTreat anemiaSkilled attendant at birtPrevent/treat bleeding with correct drugsReplace fluid loss/tranfusionInfection after deliverySkilled attendantClean practiseAntibiotics if infection arises

Causes of maternal deathsProven interventionHypertension during pregnancyDetect in pregnancyRefer to hospitalTreat eclampsia with appropriate anticonvulsiveReferunconscious womanObstructed labourDetection in time and referral for operative surgeryOther direct obstetric causesRefer ectopic pregnancy for operationIndirect causesDisease-specific intervention (malaria, HIV)

Causes of neonatal deathsProven interventionInfection (septic meningitis, pneumonia, NT, congenital syphillisTT immunization, syphillis screening and treatment, clean delivery, early and exclusive breastfeeding, early recognition and management

Causes of neonatal deathsProven interventionBirth asphyxia and traumaSkilled attendant at birthEffective management of maternal obstetric complicationPreterm birth and/or low birth weightAnti-malarials at risk during pregnancyBreastfeeding counselling and supportInfection controlEarly detection and m,anagement of complicationSTD treatmentSmoking cessation

**For each woman who dies during pregnancy, 30 women suffer complications.Initiatives should include:Family planningManagement of complications of abortionManagement of complications of pregnancy and childbirth****Maternal mortality is a global tragedy, but if affects the developing world. Almost all of the deaths from pregnancy-related complications occur in the developing world.** 50% kematian ibu terjadi di 5 propinsi: Jabar, Jateng, NTT, Banten, Jatim 25% lagi terjadi 9 propinsi: Sumut, Kalbar, Sulsel, Sulteng, Lampung, NTB, Kalsel, Aceh, Sumsel Sisanya 19 propinsi menyumbang 25% kematian ibu Propinsi penyumbang kematian ibu terbesar bukan propinsi yg memiliki angka kematian ibu tertinggi maupun cakupan persalinan yg terendah Hubungan antara cakupan persalinan dengan angka kematian ibu antar propinsi di Indonesia lemah

Dengan demikian, untuk mencapai MDG, kematian ibu di propinsi2 dengan penyumbang kematian terbesar harus diturunkan secara signifikan. Penurunan jumlah kematian ini tidak selalu terkait dengan peningkatan cakupan linakes karena pada beberapa propinsi penyumbang kematian ibu terbesar, cakupan linkaes sudah tinggi. Harus ada usaha lebih dari sekedar peningkatan cakupan linakes (beyond skilled birth attendant).

***Assalamualaikum Warahmatullahi WabarakatuhSelamat siang dan salam damai sejahtera,

Yth. Ketua, Wakil Ketua dan Anggota Panja MDGs Badan Kerjasama Antar Parlemen DPR RIYth Menteri Luar NegeriYth Kepala BappenasYth Kepala Unit Kerja Presiden Bidang Pengawasan & Pengendalian Pembangunan (UKP-PPP)Hadirin sekalian yang berbahagia

Pertama-tama marilah kita panjatkan puji dan syukur kehadirat Allah SWT, Tuhan Yang Maha Esa karena berkat rahmat dan hidayah-Nya, kita dapat bersama-sama berkumpul dalam forum yang terhormat ini untuk melaksanakan Rapat Kerja pada hari ini.

*****Assalamualaikum Warahmatullahi WabarakatuhSelamat siang dan salam damai sejahtera,

Yth. Ketua, Wakil Ketua dan Anggota Panja MDGs Badan Kerjasama Antar Parlemen DPR RIYth Menteri Luar NegeriYth Kepala BappenasYth Kepala Unit Kerja Presiden Bidang Pengawasan & Pengendalian Pembangunan (UKP-PPP)Hadirin sekalian yang berbahagia

Pertama-tama marilah kita panjatkan puji dan syukur kehadirat Allah SWT, Tuhan Yang Maha Esa karena berkat rahmat dan hidayah-Nya, kita dapat bersama-sama berkumpul dalam forum yang terhormat ini untuk melaksanakan Rapat Kerja pada hari ini.

*Masih banyak tantangan yang dilaporkan dari hasil Risfaskes 2011 dan laporan rutin program KIA antara lain:70.15% Bidan tinggal di desa64.86% Bidan di Desa yang mempunyai KitBdD mampu GDON: 10.80%,BdD telah dilatih APN: 45.63%.47,4% puskesmas perawatan mampu PONED 42,6% puskesmas PONED tersedia MgSO4

Studi Banten, sebab keterlambatan 474 kematian ibu thn 2006: 45% terlambat krn pengambilan keputusan

Data SP 2010-Litbangkes 2012SP 2010 Litbangkes 2012: 49.7%-75.3% meninggal di RS pemerintah dan swasta (tgt jenis komplikasi); 17.1-37.8% di rumah sendiriStudi di Banten: 66% terlambat mencapai fasilitas rujukan

Pelayanan Rujukan (Risfaskes 2011) Risfaskes 201121% RS Pemerintah Memenuhi Kriteria Umum PONEK 52.7% RSU pemerintah dengan Dr telah terlatih PONEK 50.4 % RSU pemerintah dengan Bidan telah terlatih PONEK

Studi di Banten: 44% terlambat mendapatkan pelayanan di RS

***The most common cause of maternal mortality is hemorrhage (24.8%), followed by infection (14.9%), obstructed labor (6.9%) and unsafe abortion (12.9%). Indirect causes account for 19.8%.**Multiple factors affect WHY a woman dies during pregnancy.The three delays model:Delay in decision to see care: lack of information about problems/warning signs, social factorsDelay in reaching care: having transportation, road conditionsDelay in receiving care: lack of equipment or personnel at facility, lack of funding, poor attitude of personnel****There have been many interventions implemented to try to improve maternal mortality. We will review the ones used to date.TBAs and antenatal care still play a role, but the role needs clarification.**Certain interventions can help prevent problems: active management of third stage of labor and clean delivery. Should be routine, however, pre-eclampsia and uterine atony cannot be prevented.**Traditional birth attendants: use has many advantages and disadvantages. The biggest disadvantage is that their skills are limited and may delay a woman getting to an appropriate level of care.**Midwifery skills: provision of emergency obstetric care. Untrained birth attendants are unable to provide emergency obstetric care.**Even with TBAs and other interventions, maternal mortality decreased in Sri Lanka. The reduction, however, was the greatest (maternal mortality was the lowest) after having births attended by skilled providers The governments commitment to this intervention was crucial.**TBAs are useful, but more skilled attendants are needed to substantially reduce maternal mortality.**Wide use of antenatal care in UK, US and Australia. Still maternal mortality in US 700/100.000 in 1940s.**Other interventions can make a difference, but not as substantial as skilled attendants. For example, in this graph, the implementation of antenatal care did not reduce maternal mortality in the UK. Improvements came only with skilled attendants who could provide surgical intervention if needed, and who had access to and could use appropriate antibiotics and blood products.Nevertheless, antenatal care remains an important intervention in maternal care because it provides an opportunity to detect problems and be prepared to handle them.**A skilled attendant should have a good range of skills, be able to identify problems, recognize complications early, be able to perform essential basic interventions and make referrals to appropriate levels of care when necessary.**Risk screening is another intervention that has been used. It is problematic because only about 10-15% of women who are thought to be at risk for a complication actually go on to have a problem. And most women who do develop complications have no risk factors. If risk factors are ruled out, the patient and provider develop a false sense of security, and are then not prepared when complications arise. All women, therefore, should be considered at risk.**

Maternal and Child Healthcare.ppt

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